Factories Act · Form 25
Form 25 — Report of Accident or Dangerous Occurrence Resulting in Death or Bodily Injury
Notice to Inspector of any accident causing death or injury disabling worker >48 hrs. Filed within 24-48 hrs of occurrence. Signed by Manager; FMO contributes injury details via Injury Register.
Rule: Rule 121(3) · Signed by: Manager · MFR 1963: Form 24
Notice to Inspector of any accident causing death or injury disabling worker >48 hrs. Filed within 24-48 hrs of occurrence. Signed by Manager; FMO contributes injury details via Injury Register.
What the form records
- ESIC employer code + insurance no. of injured
- Occupier/factory name
- Address where accident took place
- Nature of industry
- Branch/department + exact place
- Injured person name + address
- Sex, age, occupation
- Local ESIC office
- Date, shift, hour of accident
- Hour injured started work that day
- Wages payable for the day
- Cause/nature of accident
- If caused by machinery: machine + part + powered or not
- What injured was doing
- Whether injured was acting in contravention of law/orders/instructions
- If during travel: passenger to/from work? employer's transport?
- If during emergency: state nature
- Brief description of how it happened
- Witnesses (names + addresses)
- Nature + extent of injury
- Location of injury (body part)
- Whether disabled >48 hrs + return-to-work date
- Treating physician/dispensary
- Has injured died? Date of death
- Signature of manager + date despatched
Blank statutory template. Fill, save and print Form 25 in MedFactory, or view the official layout in the Model Factories Rules gazette.
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